A 24-year-old bicycle courier is brought to the emergency department after he was struck by a car. The patient was thrown approximately 6.1 m (20 ft) through the air and was initially unconscious when other eyewitnesses reached him. On arrival, blood pressure is 84/54 mm Hg, pulse is 130/min, and respirations are 28/min. Oxygen saturation is 88% on 100% oxygen via a nonrebreather mask. The patient appears extremely anxious and in respiratory distress. When he sees the trauma team preparing supplies for intubation, the patient says, "No, no tube!" However, soon afterward, the patient loses consciousness while resuscitative efforts and trauma survey examination are ongoing. Which of the following is the most appropriate course of action?

Question

A 24-year-old bicycle courier is brought to the emergency department after he was struck by a car.  The patient was thrown approximately 6.1 m (20 ft) through the air and was initially unconscious when other eyewitnesses reached him.  On arrival, blood pressure is 84/54 mm Hg, pulse is 130/min, and respirations are 28/min.  Oxygen saturation is 88% on 100% oxygen via a nonrebreather mask.  The patient appears extremely anxious and in respiratory distress.  When he sees the trauma team preparing supplies for intubation, the patient says, "No, no tube!"  However, soon afterward, the patient loses consciousness while resuscitative efforts and trauma survey examination are ongoing.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: Informed consent is typically required prior to performing any procedure on a patient; this respects patient autonomy, allowing patients to make educated decisions about their own health care. A main exception to the rule is when a life-saving procedure is necessary in an emergency and obtaining consent is not possible. Informed consent Informed refusal is the negative corollary of informed consent: if appropriately informed, patients with decision-making capacity can refuse life-saving treatment (eg, intubation). However, this requires that the same information be discussed with the patient as is typically discussed for informed consent, including: The diagnosis The proposed procedure or treatment, along with its risks/benefits Alternative treatment options, along with their risks/benefits The risks of refusing treatment Although this patient stated, "No, no tube," he decompensated so quickly (eg, while trauma survey and resuscitative efforts were ongoing) that the discussion necessary for informed refusal could not be completed. In the absence of informed refusal, the physician should act in the patient's best interest and proceed with emergency endotracheal intubation, a life-saving procedure (Choice C). A final consideration in this case is that, due to emotional (eg, fear) and/or physiological (eg, brain hypoperfusion) derangements resulting from trauma and/or hypovolemic shock, this patient may have temporarily lacked decision-making capacity to give informed refusal (or consent). (Choices A and B) Surrogate consent from the next of kin or the ethics committee is unnecessary to perform intubation in this emergency, life-threatening situation. In addition, delaying intubation to contact either party would likely cause harm to the patient. (Choice E) Endotracheal intubation, rather than tracheostomy, is the standard of care (ie, acting in the patient's best interest) for obtaining a secure airway in the absence of upper airway obstruction and involves less risk (ie, do no harm) to this patient with a life-threatening condition. (Choice F) Informed consent is unnecessary in this patient's emergency, life-threatening situation. Although the rationale for the emergency treatment will likely be discussed with the patient after he recovers, informed consent is never obtained retroactively. Educational objective: Life-saving procedures (eg, intubation) may be performed without informed consent in emergencies, when obtaining consent is not possible. Informed refusal requires discussion of all the same elements (eg, diagnosis, proposed procedure, risks/benefits, alternatives, risks of refusal) required for informed consent. References: How to effectively obtain informed consent in trauma patients: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/30674301) How should trauma patients' informed consent or refusal be regarded in a trauma bay or other emergency settings? (http://www.ncbi.nlm.nih.gov/pubmed/29763388)

A 24-Year-Old Bicycle Courier Is Brought to the Emergency Department